Laparoscopic instrument and cannula assembly and related surgical method

ABSTRACT

A laparoscopic port assembly includes a cannula unit including three cannulas each extending at an acute angle relative to a base. The cannulas are flexible for receiving respective angulated laparoscopic instruments. The cannula unit is rotatingly received in a port holder for rotation about a longitudinal axis of the holder, the holder being disposable in an opening in a patient&#39;s skin.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of, and claims priority to, U.S.patent application Ser. No. 12/779,294, filed on May 13, 2010 by Piskunet al, published as U.S. Patent Application Publication No. US2010/0222643 A1 and now U.S. Pat. No. 8,460,271, which is a divisionalof, and claims priority to, U.S. patent application Ser. No. 10/895,546by Piskun et al. filed on Jul. 21, 2004, now U.S. Pat. No. 7,753,901issued on Jul. 13, 2010, entitled “LAPAROSCOPIC INSTRUMENT AND CANNULAASSEMBLY AND RELATED SURGICAL METHOD”, the entire contents of both ofwhich are hereby incorporated by reference herein. This applicationincorporates by reference herein in its entirety PCT applicationPCT/US2005/024111 by Piskun et al. having an international filing dateof Jul. 7, 2005 and published as WO 2006/019592 A2 “LAPAROSCOPICINSTRUMENT AND CANNULA ASSEMBLY (sic) AND RELATED SURGICAL METHOD” onFeb. 23, 2006.

FIELD OF THE INVENTION

The present invention relates to surgical instruments, surgical portassemblies, and an associated method. The instruments, port assembliesand method are particularly useful in the performance of laparoscopicprocedures entirely through the umbilicus.

BACKGROUND OF THE INVENTION

Abdominal laparoscopic surgery gained popularity in the late 1980's,when benefits of laparoscopic removal of the gallbladder overtraditional (open) operation became evident. Reduced postoperativerecovery time, markedly decreased post-operative pain and woundinfection, and improved cosmetic outcome are well established benefitsof laparoscopic surgery, derived mainly from the ability of laparoscopicsurgeons to perform an operation utilizing smaller incisions of the bodycavity wall.

Laparoscopic procedures generally involve insufflation of the abdominalcavity with CO2 gas to a pressure of around 15 mm Hg. The abdominal wallis pierced and a 5-10 mm in diameter straight tubular cannula or trocarsleeve is then inserted into the abdominal cavity. A laparoscopictelescope connected to an operating room monitor is used to visualizethe operative field, and is placed through (one of) the trocarsleeve(s). Laparoscopic instruments (graspers, dissectors, scissors,retractors, etc.) are placed through two or more additional trocarsleeves for the manipulations by the surgeon and surgical assistant(s).

Recently, so-called “mini-laparoscopy” has been introduced utilizing 2-3mm diameter straight trocar sleeves and laparoscopic instruments. Whensuccessful, mini-laparoscopy allows further reduction of abdominal walltrauma and improved cosmesis. However, instruments used formini-laparoscopic procedures are generally more expensive and fragile.Because of their performance limitations, due to their smaller diameter(weak suction-irrigation system, poor durability, decreased videoquality), mini-laparoscopic instruments can generally be used only onselected patients with favorable anatomy (thin cavity wall, fewadhesions, minimal inflammation, etc.). These patients represent a smallpercentage of patients requiring laparoscopic procedure. In addition,smaller, 2-3 mm, incisions may still cause undesirable cosmetic outcomesand wound complications (bleeding, infection, pain, keloid formation,etc.).

Since the benefits of smaller and fewer body cavity incisions areproven, it would be attractive to perform an operation utilizing only asingle incision in the navel. An umbilicus is the thinnest and leastvascularized, and a well-hidden, area of the abdominal wall. Theumbilicus is generally a preferred choice of abdominal cavity entry inlaparoscopic procedures. An umbilical incision can be easily enlarged(in order to eviscerate a larger specimen) without significantlycompromising cosmesis and without increasing the chances of woundcomplications. The placement of two or more standard (straight) cannulasand laparoscopic instruments in the umbilicus, next to each other,creates a so-called “chopstick” effect, which describes interferencebetween the surgeon's hands, between the surgeon's hands and theinstruments, and between the instruments. This interference greatlyreduces the surgeon's ability to perform a described procedure.

Thus, there is a need for instruments and trocar systems, which allowlaparoscopic procedures to be performed entirely through the umbilicuswhile at the same time reducing or eliminating the “chopstick effect”. Alaparoscopic procedure performed entirely through the umbilicus, usingthe laparoscopic instruments and trocar system according to anembodiment of the present invention, allows one to accomplish thenecessary diagnostic and therapeutic tasks while further minimizingabdominal wall trauma and improving cosmesis.

OBJECTS OF THE INVENTION

The present invention provides instruments and cannula or portassemblies for the performance of surgical procedures, particularlyincluding laparoscopic procedures, for instance, entirely through theumbilicus.

An object of the present invention is to provide an improved portassembly for facilitating access to internal organs of a patient duringlaproscopic procedures.

Another object of the present invention is to provide such a portassembly that provides enlarged workspace for the hands of thesurgeon(s) when plural laparoscopic instruments are placed through theumbilicus.

An additional object of the present invention is to provide improvedlaparoscopic instruments for facilitating operations through theumbilicus.

These and other objects of the invention will be apparent from thedrawings and descriptions herein. Although each object of the inventionis believed to be attained by at least one embodiment of the invention,there is not necessarily any single embodiment that achieves all of theobjects of the invention.

SUMMARY OF THE INVENTION

The present invention facilitates the performance of laparoscopicsurgical procedures wherein several laparoscopic instruments areinserted into a patient through respective cannulas all extendingthrough the same opening in the patient, for instance, through theumbilicus. The advantages of such an operation include minimizing traumato the patient and accelerating the patient recovery.

A surgical port assembly that facilitates the performance of such alaparoscopic surgical procedure comprises, in accordance with thepresent invention, a cannula unit including at least one cannula member,and a holder disposable in an opening in a patient's skin for receivingthe cannula component so that the cannula component is movable relativeto the holder during a surgical procedure. Preferably, the cannula unitis rotatable with respect to the holder about a longitudinal axis of theholder. It is contemplated that the holder is fastened to the patientduring the surgical operation, so that the cannula unit is movablerelative to the patient.

Pursuant to another feature of the present invention, the cannula unitcomprises a base or frame that is removably attachable to the holder andthat defines a closure surface extending, during the surgical procedure,substantially tangentially to the patient's skin at the opening. Thecannula member is connected to the base and defines an access paththrough the closure surface. The cannula member extends at an acuteangle relative to the closure surface so that the cannula is inclinedrelative to the patient's skin surface during the surgical procedure.

Pursuant to further features of the present invention, the cannula isflexible and has a relaxed configuration that is linear. The base orframe is provided with a panel or wall forming the closure surface.

In a particular embodiment of the present invention, the cannula is oneof a plurality of cannulas each extending at an acute angle relative tothe closure surface so that the cannulas are all inclined relative tothe patient's skin surface during the surgical procedure.

Pursuant to additional features of the present invention, the cannulaunit is partially insertable into the holder, while the port assemblyfurther comprises a connector member for removably attaching the cannulaunit to the holder, the connector also being partially insertable intothe holder.

The holder and the connector member may be provided with cooperatinglocking elements such as projections and slots for reversibly securingthe cannula unit to the holder. Thus, after placement of the holder inan opening in the patient (and after removal of an insert assist memberfrom the holder), the base or frame of the cannula unit is inserted intothe holder and secured thereto by an insertion and a rotation of theconnector so that the projections and slots are interlocked.

The base or frame of the cannula unit may include a frustoconicalportion insertable into the holder. Similarly, the connector may includea frustoconical portion insertable into the holder to secure the cannulaunit to the holder. The holder is provided internally with a shoulderengaging a lower end of the cannula unit.

As indicated above, in one embodiment of the present invention, asurgical port assembly comprises (a) a base or frame seatable in anopening in a patient's skin and defining a closure surface extendingsubstantially tangentially to the patient's skin at the opening during asurgical procedure and (b) a cannula connected to the base and definingan access path through the closure surface. The cannula extends at anacute angle relative to the closure surface so that the cannula isinclined relative to the patient's skin surface during the surgicalprocedure. The cannula may be one of a plurality of cannulas eachextending at an acute angle relative to the closure surface so that thecannulas are all inclined relative to the patient's skin surface duringthe laparoscopic procedure.

Where the closure surface is located in a main plane, the cannulas havelinear configurations, and the base or frame has a longitudinal axis,each of the cannulas may define a respective secondary plane orientedperpendicularly to the main plane, each the secondary plane being spacedfrom the longitudinal axis. The cannulas may be three in number with thesecondary planes disposed at angles of 120° relative to each other.

A surgical method in accordance with the present invention comprisesforming an opening in a patient, inserting a cannula holder through theopening, disposing a plurality of cannulas in the holder so that afterinserting of the holder the cannulas traverse the holder and extend fromoutside the patient to inside the patient, thereafter inserting aplurality of elongate medical instruments through the respectivecannulas, and rotating the cannulas and the instruments relative to theholder, about a longitudinal axis of the holder.

In accordance with another aspect of the present invention, where thecannulas are attached to a base member, the disposing of the cannulas inthe holder includes inserting the base member into the holder, the basemember being in rotatable engagement with the holder. The disposing ofthe cannulas in the holder may further include attaching a lockingmember to the holder to maintain the base member in rotatable engagementwith the holder.

A laparoscopic medical instrument insertable through a laparoscopictrocar sleeve comprises, in accordance with the present invention, anelongate shaft, an operative tip disposed at one end of the shaft, and afirst actuator disposed at an opposite end of the shaft. The actuator isoperatively connected to the operative tip via the shaft for controllingthe operation of the operative tip. The shaft has a straight proximalend portion, a curved middle portion and a straight distal end portion,the distal end portion extending at an angle with respect to theproximal end portion. The proximal end portion is provided with a firstrotary joint so that the distal end portion and the operative tip arerotatable about a longitudinal axis of the proximal end portion. Thedistal end portion is provided with a second rotary joint so that theoperative tip is rotatable about a longitudinal axis of the distal endportion. A second actuator disposed at the end of the shaft opposite theoperative tip is operatively connected to the proximal end portion ofthe instrument shaft for rotating the distal end portion thereof and theoperative tip about the longitudinal axis of the proximal end portion ofthe shaft. A third actuator disposed at the end of the shaft oppositethe operative tip is operatively connected to the distal end portion ofthe shaft for rotating the operative tip about the longitudinal axis ofthe distal end portion.

The proximal end portion, the middle portion and the distal end portionof the instrument shaft are each substantially rigid throughout so thatthey cannot be bent. In one embodiment of the invention, the instrumentshaft has a hockey-stick shape. Two laparoscopic surgical instrumentseach having a hockey stick shape are advantageously used in a crossedconfiguration, which markedly improves the degrees of freedom of theinstruments, particularly during lateral (medial-lateral) movements.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a laparoscopic port having multiplecannulas, in accordance with the present invention.

FIG. 2 is a cross-sectional view of the laparoscopic port or cannulaassembly of FIG. 1, taken along line II-II in FIG. 3.

FIG. 3 is a top view of the laparoscopic port or cannula assembly ofFIG. 1.

FIG. 4 is a perspective view of an annular holder disposable in anopening in a patient for receiving the laparoscopic port or cannulaassembly of FIGS. 1-3.

FIG. 5 is a top plan view of the port holder of FIG. 4.

FIG. 6 is a longitudinal cross-sectional view of the port holder ofFIGS. 4 and 5, taken along line VI-VI in FIG. 5.

FIG. 7 is another longitudinal cross-sectional view of the port holderof FIGS. 4 and 5, taken along line VII-VII in FIG. 5.

FIG. 8 is a perspective view of the laparoscopic port or cannulaassembly of FIGS. 1-3, together with the port holder of FIGS. 4-7,showing the laparoscopic port or cannula assembly inserted into andattached to the port holder.

FIG. 9 is a top plan view of the laparoscopic port or cannula assemblyof FIGS. 1-3 connected to the port holder of FIGS. 4-7, as shown in FIG.8.

FIG. 10 is a longitudinal cross-sectional view taken along line X-X inFIG. 9.

FIG. 11 is a perspective view of a cannula with an insufflation valve,included in the laparoscopic port or cannula assembly of FIGS. 1-3 and8-10.

FIG. 12 is a side elevational view of the cannula of FIG. 11, on alarger scale.

FIG. 13 is a longitudinal cross-sectional view of the cannula of FIGS.11 and 12, taken along line XIII-XIII in FIG. 12.

FIG. 14 is a transverse cross-sectional view of the cannula of FIGS. 11and 12, taken along line XIV-XIV in FIG. 12.

FIG. 15 is a perspective view of a cannula without an insufflationvalve, included in the laparoscopic port or cannula assembly of FIGS.1-3 and 8-10.

FIG. 16 is a side elevational view of the cannula of FIG. 16, on alarger scale.

FIG. 17 is a longitudinal cross-sectional view of the cannula of FIGS.15 and 16, taken along line XVII-XVII in FIG. 16.

FIG. 18 is a transverse cross-sectional view of the cannula of FIGS. 15and 16, taken along line XVIII-XVIII in FIG. 16.

FIG. 19 is a perspective view of an insertion plug used to facilitateinsertion of the port holder of FIGS. 4-7 in a patient at the beginningof a laparoscopic procedure.

FIG. 20 is a top perspective view of the insertion plug of FIG. 19temporarily inserted in and attached to the port holder of FIGS. 4-7.

FIG. 21 is a top plan view of the assembled insertion plug and portholder of FIG. 20.

FIG. 22 is a longitudinal cross-section taken along line XXII-XXII inFIG. 21.

FIG. 23 is a bottom perspective view of the assembled insertion plug andport holder of FIGS. 20-22.

FIG. 24 is a side elevational view of a laparoscopic instrumentutilizable with the multiple-cannula port assembly of FIGS. 8-10, inaccordance with the present invention.

FIG. 25 is a top plan view of the laparoscopic instrument of FIG. 24.

FIG. 26 is partially a side elevational view and partially across-sectional view

FIG. 27 is a partial longitudinal cross-sectional view also taken alongline XXVI-XXVI in FIG. 25.

FIG. 28 is a longitudinal cross-sectional view, on a larger scale, of adistal end of the laparoscopic instrument of FIGS. 24-27.

FIG. 29 is a longitudinal cross-sectional view, on an even larger scale,taken along line IXXX-IXXX in FIG. 28.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

As depicted in FIGS. 1-3, a laparoscopic port or cannula assembly 100comprises a cannula unit 102 and a connector 104 associated therewithfor removably fastening the cannula unit to an annular port holder 106(FIGS. 4-8 and 10) that is disposed in an opening (e.g., formed in theumbilicus) in a patient. Cannula unit 102 is coupled to port holder 106by connector 104 so as to permit rotation of cannula unit 102 about alongitudinal axis 108 (FIGS. 7 and 10) of holder 106. Holder 106 has aninner side facing the patient and an outer side facing outside thepatient during a laparoscopic procedure, and axis 108 traverses theholder from the inner side to the outer side thereof.

Cannula unit 102 comprises a base or frame 110 that is insertable intoand removably attachable to port holder 106. Base or frame 110 includesa base member in the form of a planar panel or wall 112 that defines aclosure surface or plane SC extending, during a laparoscopic surgicalprocedure, substantially tangentially and accordingly parallel to thepatient's skin at the opening through with port holder 106 extends. Baseor frame 110 further includes a seating ring 114 and a sealing ring 116.

Cannula unit 102 additionally comprises three cannula members 118, 120,122 each connected to base or frame 110 and defining a respective accesspath through closure surface SC. Cannulas 118, 120, 122 are eachconnected at one end to base 110 and particularly panel or wall 112 atmutually spaced locations so as to enable simultaneous insertion ofmultiple instruments through closure surface SC at such locations, thecannulas each extending away from closure surface SC so as to be locatedon only an outer side thereof opposite the patient during a surgicalprocedure. Cannula members 118, 120, 122 have outer surfaces (notseparately designated) that are contiguous with, and stationary withrespect to, planar panel or wall 112 at points of passage of thecannulas through the panel or wall. When cannula unit 102 and holder 106are connected together (see FIG. 10), cannula members 118, 120, 122extend into and are partially surrounded by said holder 106 and enabledisposition of distal ends of three separate instruments in the patientat an opening or incision in the patient. Cannula members 118, 120, 122each extend at an acute angle relative to closure surface SC so that thecannulas are inclined relative to the patient's skin surface during alaparoscopic surgical procedure. Cannula members 118, 120, 122 includeflexible tubular portions 124, 126, 128 that have linear configurationsin a relaxed or unstressed condition.

Each cannula member 118, 120, 122 defines a respective plane P1, P2, P3(FIG. 3) oriented perpendicularly to closure surface or plane SC (themain plane) and spaced from a longitudinal axis 130 of base or frame110. These secondary planes P1, P2, and P3 are disposed at angles of120° relative to each other, as indicated in FIG. 3. Connector 104 isloosely coupled to cannula unit 102 so as to be freely movable alongaxis 130 of the cannula unit, between base 110 and valve components ofcannulas 118, 120, 122.

Connector 104 includes a frustoconical portion 132 insertable into portholder 106 (see FIG. 10) and further includes a pair of flanges 134, 136for temporarily locking cannula unit 102 to holder 106. To that end,flanges 134, 136 are provided with dual-lobed slots 138, 140 forreceiving respective pins or projections 142, 144 on port holder 106(see FIGS. 4, 5, 7, 8, 9). Flanges 134 and 136 are also provided withrespective pairs of upturned ears 146 and 148 functioning in part asthumb and finger rests for swiveling connector 104 about axis 108 (and130) to reversibly secure connector 106 and concomitantly cannula unit102 to port holder 106.

As illustrated in FIGS. 4-7, port holder 106 includes an annularperipheral wall in the form of a tapered, slightly frustoconical sleeve150 provided along an outer surface with a pair of annular beads or ribs152 and 154 and along an inner surface with a shoulder 156 that servesas an abutment or rest for seating ring 114 of cannula unit 102.Peripheral wall or sleeve 150 is an outermost portion of holder 106 andis in contact with tissues of said patient upon a disposition of theholder in an opening of the patient. At a wider end of sleeve 150,holder 106 includes a pair of diametrically opposed flanges 158, 160 anda pair of diametrically opposed ears 162, 164. Pins or projections 142,144 are rigid with flanges 158, 160, while ears 162, 164 carryrespective flat-headed posts 166, 168 around which sutures are wound tofasten holder 106 to the skin of the patient. Rubber gaskets 167 and 169may be provided for clamping suture threads to posts 166 and 168.Alternatively or additionally, sutures anchoring port holder 106 to thebody wall of the patient may be inserted through slots 163 a, 163 b and165 a, 165 b and partially wrapped around bases 171 and 173 of ears 162,164 (see FIG. 5).

After placement of holder 106 in an opening in the patient (and afterremoval of an insert assist member 170, FIGS. 19-22, from the holder),base or frame 110 of cannula unit 102 is inserted into holder 106 untilseating ring 114 engages shoulder 15 (see FIG. 10). Cannula unit 110 issecured to holder 106 by an insertion and a subsequent rotation ofconnector 104 relative to holder 106, as indicated by an arrow 172 inFIGS. 8 and 9, so that projections 142, 144 and slots 138, 140 areinterlocked (see FIGS. 8-10). After this locking of connector 104 toholder 106, cannula unit 102 is rotatable about axes 108 and 130 inopposition to a frictional drag force exerted by virtue of sealing ring116.

As illustrated in FIGS. 11-14, cannula unit 118 includes valve component174 connected to tubular portion 124. Valve component 124 includes aninsufflation port 175 for receiving a tube (not shown) for guidingcarbon dioxide gas from a pressurized source into the patient. As shownparticularly in FIG. 13, valve component 124 of cannula member 118includes a valve box or casing 176 with a cover or closure 178 to whichan extension tube 180 is attached. At an end opposite valve casing 176,extension tube 180 is provided with a sleeve 182, a valve seal 184, adisc 185, and a cap 186. Valve component 174 further includes a valvedoor 188 that is biased into a closure position shown in FIG. 13 by ahelical or coil spring 190. Door 188 is supported by a mounting bracketand associated hardware 191. An O-ring seal 192 is provided forinhibiting the escape of insufflation gas from a patient throughextension tube 124 when a laparoscopic surgical instrument does nottraverse cannula member 118.

As illustrated in FIGS. 1-3 and 8-10, cannula members 120 and 122include respective valve components 194 and 196 connected to respectiveflexible tubular portions 126 and 128. These valve components arestructurally identical, a representative component 194 being depicted inFIGS. 15-18. Valve component 194 includes a valve box or casing 198 witha cover or closure 200 to which an extension tube 202 is attached. At anend opposite valve casing 198, extension tube 202 is provided with asleeve 204, a valve seal 206, a disc 208, and a cap 210. Valve component194 further includes a valve door 212 that is biased into a closureposition shown in FIG. 17 by a helical or coil spring 214. Door 212 issupported by a mounting bracket and associated hardware 216. An O-ringseal 218 is provided for inhibiting the escape of insufflation gas froma patient through extension tube 202 when a laparoscopic surgicalinstrument does not traverse the respective cannula member 120 (or 122).

As shown in FIG. 19, insert assist member 170 includes a rounded conicaltip 220, a cylindrical middle portion 222 and a slightly tapered orfrustoconical outer portion 224. Outer portion 224 is provided with apair of flanges 226, 228 for temporarily locking insert assist member170 to port holder 106. To that end, flanges 226, 228 are provided withdual-lobed slots 230, 232 for receiving respective pins or projections142, 144 on port holder 106, as depicted in FIGS. 20-22. Flanges 226 and228 are formed with respective pairs of upturned ears 234 and 236 thatare manually engageable by a user to reversibly secure connector insertassist member 170 to port holder 106.

After a small incision or opening is made in a patient, port holder 106with insert assist member 170 connected thereto is inserted through theincision. Sutures (not shown) are stitched to the patient and are woundaround and tied to posts 166, 168 to firmly secure the port holder 106to the patient. Insert assist member 170 is then removed, by a reverserotation unlocking flanges 226, 228 from pins or projections 142, 144and by separating the insert assist member from holder 106. Cannula unit102 is then attached to holder 106 as described above.

FIGS. 24-29 depict a laparoscopic surgical instrument 238 insertablethrough a laparocopic trocar sleeve or cannula such as cannula member118, 120, or 122 of the port assembly of FIGS. 1-3 and 8-10 forexecuting a laparoscopic surgical operation. Instrument 238 comprises anelongate shaft 240, an operative tip 242 disposed at one end of theshaft, and a hand-grip-type actuator 244 disposed at an opposite end ofthe shaft. Actuator 244 is operatively connected to operative tip 242via shaft 240 for controlling the operation of the operative tip.

Shaft 240 has a straight proximal end portion 246, a curved middleportion 248 and a straight distal end portion 250, the distal endportion extending at a non-zero angle with respect to the proximal endportion, as shown in FIGS. 24, 26 and 27. Proximal end portion 246 isprovided with a first rotary joint 252 so that distal end portion 250and operative tip 242 are rotatable about a longitudinal axis 254 ofproximal end portion 246. Distal end portion 250 is provided with asecond rotary joint 256 so that operative tip 242 is rotatable about alongitudinal axis 258 of the distal end portion. A rotary actuator orknob 260 disposed at the proximal end of instrument 238 is operativelyconnected to proximal end portion 246 of instrument 240 for rotatingdistal end portion 250 and operative tip 242 about longitudinal axis254. Another rotary actuator or knob 262 disposed at the proximal end ofinstrument 238 is operatively connected to distal end portion 250 ofshaft 240 for rotating operative tip 242 about longitudinal axis 258.

Proximal end portion 246, middle portion 248 and distal end portion 250of instrument shaft 240 are each substantially rigid throughout and canonly be rotated about joints 252 and 256 and not bent. The angle betweenaxes 254 and 258 are such that shaft 240 has a shape reminiscent of ahockey stick. In an alternative embodiment of instrument 238, middleportion 248 of shaft 240 may be flexible to permit shaft 240 toalternately assume a linear configuration and the hockey-stickconfiguration of FIGS. 24 and 26. In that case, a handle assembly 274 isprovided with an actuator (not shown) for enabling a bending of middleportion 248.

As shown in FIGS. 24-26, instrument 238 may be provided with furtheractuators, such as a slidable toggle switch 264, for example forperforming a locking function or inducing a pivoting of operative tip242 about an axis perpendicular to axis 258.

Actuator 244 includes a hand grip member 266 fixed relative to shaft 240and further includes a pivotable hand grip 268. A proximal end 270 ofshaft 240 is journaled in a bearing 272 about which rotary knob 262.Actuator 244, rotary knobs 260 and 262, and toggle switch 264 are partsof a handle assembly 274 also incorporating yokes 276 and 278, a stopperpin 278, a set screw 280.

FIG. 27 illustrates further parts of a shaft assembly 282 includingshaft 240, a slider member 283, a socket set screw 284, an outer bearing286, a motion bar 288, a bend tube 290, a ring 292, and an O-ring seal294.

Rotary joint 256 is representative of joint 254 and comprises, as shownin FIG. 27, a proximal pin or inner shaft portion 296, a distal pin orinner shaft portion 298, a pair of coupling elements 300 and 302, and atransverse connector pin 304.

As illustrated in FIGS. 28 and 29, operative tip 242 exemplarilyincludes a pair of jaws 306 and 308 pivotably connected to a distal endof distal end portion 250 via a pivot pin 310. Jaws 306 and 308 arerotatable about pin 310 through the action of levers or arms 312, 314that pivot in response to a longitudinal motion of a tip rod 316.

After a deployment of cannula unit 102 in a patient as described above,operative tip 242 and shaft 240 of instrument 238 are insertable througha cannula member 118, 120, or 122, with the respective tubular portion124, 126, or 128 bending to accommodate the bent shaft 240. The bentshape of shaft 240, as well as the rotary joints 252 and 256 facilitatethe performance of laparoscopic surgical procedure using multiplelaparoscopic instruments extending through a single opening in apatient, for instance, in the umbilicus. Such a procedure involves therotation of distal end portion 250 and operative tip 242 together aboutaxis 254 and the rotation of operative tip about axis 258. In addition,the entire instrument assembly including cannula unit 102 and multipleinstruments 238 can be rotated about collinear axes 108 and 130, tooptimize the simultaneous or successive access of multiple operativetips 242 to a surgical site inside a patient.

Although the invention has been described in terms of particularembodiments and applications, one of ordinary skill in the art, in lightof this teaching, can generate additional embodiments and modificationswithout departing from the spirit of or exceeding the scope of theclaimed invention. Accordingly, it is to be understood that the drawingsand descriptions herein are proffered by way of example to facilitatecomprehension of the invention and should not be construed to limit thescope thereof.

What is claimed is:
 1. An insert assist member for inserting a portholder in an opening at a surgical site comprising: a proximal outerportion; a cylindrical middle portion extending distally from theproximal outer portion; and a distal tip portion extending distally fromthe cylindrical middle portion, the distal tip portion defining arounded tip for insertion through an aperture defined in a port holderconfigured for insertion in said opening at a surgical site; and,wherein the proximal outer portion includes a pair of flange memberseach configured to define an aperture therethrough, the pair of flangemembers configured such that the apertures receive and rotatably engagewith corresponding projections extending proximally from the portholder.
 2. The insert assist member according to claim 1, wherein thepair of flange members are configured such that the apertures disengagefrom the projections upon rotation of the pair of flange members in adirection opposite the direction in which the apertures engage with theprojections.
 3. The insert assist member according to claim 2, whereinthe insert assist member is removable from the port holder upon rotationof the pair of flange members in the direction opposite the direction inwhich the apertures engage with the projections.
 4. The insert assistmember according to claim 1, wherein the apertures are each a dual-lobedslot configured to receive a corresponding projection extendingproximally from the port holder.
 5. The insert assist member accordingto claim 1, wherein the pair of flange members each are configured withrespective pairs of upturned ears that are manually engageable toreversibly secure the insert assist member to the port holder.
 6. Amethod of inserting a port holder in an opening at a surgical sitecomprising: providing an insert assist member configured to at leastpartially fit within the port holder to form a port holder and insertassist member assembly, the insert assist member having an atraumaticdistal tip; positioning the insert assist member within the port holdersuch that the atraumatic distal tip extends distally beyond a distal endof the port holder; and inserting the port holder and insert assistmember assembly in the opening; and, wherein the port holder includes atleast one proximally extending projection and said insert assist memberdefines an aperture for receiving the at least one projection, the stepof positioning the insert assist member within the port holder furtherincluding aligning the port holder and insert assist member to place theprojection into the aperture.
 7. The method of inserting a port holderaccording to claim 6, further comprising securing the port holder to thesurgical site via winding of sutures around posts configured anddisposed in the port holder to enable one or more sutures to be woundaround the posts to enable the port holder to be fastened to thesurgical site.
 8. The method of inserting a port holder according toclaim 6, further comprising disengaging the insert assist memberproximally from the port holder.